Medicare Appeals Lead - Operations & Compliance

Highmark Health; Pennsylvania; Hybrid; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a supervisor for the Medicare Fee-for-Service appeals unit within the Organization's Medicare Services.

You will delegate assignments, manage resources, and ensure CMS thresholds and internal standards are met, while guiding non-clinical staff in pay/deny decisions and coordinating with external contractors. The role includes budget assistance, performance monitoring, staff coaching, and provider education coordination to improve overall Medicare Services performance,

Qualifications

• Minimum High School diploma or GED.
• 1-3 years of experience in a leadership/supervisory position.
• Preferred Bachelor’s degree and 3 years of experience in a healthcare industry.
• Associates degree and 5 years of experience in a healthcare industry.

Responsibilities

• Displays effective communication skills.
• Verbal and written communication with Director and Senior Management, peers, departmental staff, and various Corporate support departments
• Verbal and written communication with external business partners including Program Safeguard Contractors (PSC), Recovery Audit Contractors (RAC), and Qualified Independent Contractors (QIC) and vendors
• Verbal and written communication with our customers including the Centers for Medicare and Medicaid Services (CMS), providers, and beneficiaries.
• Contribute to the achievement of the department performance standards specified in the Statement of Work, budget, CMS internet only manual, award fee, EIP or other program memoranda.
• Delegate work assignments to sustain department performance.
• Assist with budget preparation and monitoring.
• Monitor inventory levels and move resources, schedule cross training, etc… to effectively manage to CMS thresholds.
• Ensure compliance with management controls, process quality plans, change requests, internal and external audits, etc.
• Document department protocols and controls.

Skills

Leadership experience

Effective communication

Budget monitoring

CMS regulations knowledge

Supervisory skills

Education

High School diploma or GED

Bachelor’s degree (preferred)

Associates degree with 5 years (healthcare)

Tools

MCS/FISS

Microsoft Windows

Job description

Highmark Inc. is seeking a supervisor for the Medicare Fee-for-Service appeals unit within the Organization's Medicare Services.

You will delegate assignments, manage resources, and ensure CMS thresholds and internal standards are met, while guiding non-clinical staff in pay/deny decisions and coordinating with external contractors. The role includes budget assistance, performance monitoring, staff coaching, and provider education coordination to improve overall Medicare Services performance,